Provider Demographics
NPI:1578579595
Name:SUGIMOTO, TED (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:SUGIMOTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6416 DEANS HILL RD
Mailing Address - Street 2:
Mailing Address - City:BERRIEN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49102-9750
Mailing Address - Country:US
Mailing Address - Phone:269-471-7741
Mailing Address - Fax:269-471-1581
Practice Address - Street 1:3950 HOLLYWOOD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9159
Practice Address - Country:US
Practice Address - Phone:269-429-0900
Practice Address - Fax:269-408-0996
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041051208600000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIBS2273275OtherDEA
E77321Medicare UPIN